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Cardiology Flashcards

1
Q

Define AAA.

A

A localised enlargement of the abdominal aorta such that the diameter is > 3 cm or > 50% larger than normal diameter.

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2
Q

What is the normal diameter of an aorta?

A

2 cm

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3
Q

What are the risk factors for AAA?

A

Severe atherosclerotic damage to aortic wall

Family history

Smoking

Male

Age

Hypertension

Hyperlipidaemia

Connective tissue disorders: Marfan’s syndrome, Ehlers-Danlos syndrome

Inflammatory disorders: Behcet’s disease, Takayasu’s arteritis

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4
Q

What are the presenting symptoms of an unruptured AAA?

A

NO SYMPTOMS

Usually an incidental finding

May have pain in the back, abdomen, loin or groin

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5
Q

What are the presenting symptoms of a ruptured AAA?

A

Pain in the abdomen, back or loin

Pain may be sudden or severe

Syncope

Shock

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6
Q

What are the signs of an AAA on examination?

A

Pulsatile and laterally expansile mass on bimanual palpation of the abdominal aorta

Abdominal bruit

Retroperitoneal haemorrhage can cause Grey-Turner’s sign (brusing of the flanks)

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7
Q

What are the appropriate investigations for an AAA?

A

o Bloods - FBC, clotting screen, renal function and liver function

o Scans - Ultrasound, CT with contrast (shows whether an aneurysm has ruptured), MRI angiography

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8
Q

Define aortic dissection.

A

A condition where a tear in the aortic intima allows blood to surge into the aortic wall, causing a split between the inner and outer tunica media, creating a false lumen.

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9
Q

What are the risk factors for aortic dissection?

A

HYPERTENSION

Aortic atherosclerosis

Connective tissue disease (e.g. Marfan’s, Ehlers-Danlos, SLE)

Congenital cardiac abnormalities (e.g. coarctation of the aorta)

Aortitis

Iatrogenic (e.g. during angioplasty/angiography)

Trauma

Crack cocaine

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10
Q

What is a potential consequence of expansion of the false lumen in aortic dissection?

A

o obstructions of the subclavian, carotid, coeliac and renal arteries

  • hypoperfusion of the target organs of these major arteries can give rise to other symptoms (e.g. carotid artery –> collapse)
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11
Q

What are the presenting symptoms of aortic dissection?

A

o MAIN SYMPTOM: sudden central ‘TEARING’ pain which may radiate to the back in between the shoulder blades - can mimic MI

  • Other symptoms caused by obstruction of branches of the aorta:
  • Carotid artery –> hemiparesis, dysphasia, blackout
  • Coronary artery –> chest pain (angina or MI)
  • Subclavian artery –> ataxia, loss of consciousness
  • Anterior spinal artery –> paraplegia
  • Coeliac axis –> severe abdominal pain (due to ischaemic bowel)
  • Renal artery –> anuria, renal failure
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12
Q

What are the signs of aortic dissection on examination?

A

o Murmur on the back (below the left scapula), descending to the abdomen

o Hypertension

o Blood pressure difference between the two arms > 20 mm Hg

o Wide pulse pressure

o Hypotension may suggest tamponade

o Signs of Aortic Regurgitation -> high volume collapsing pulse, early diastolic murmur over aortic area

o Unequal arm pulses

o Palpable abdominal mass

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13
Q

What is pulsus paradoxus?

A

o abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration

  • may indicate: Tamponade, Pericarditis, Chronic sleep apnoea, Obstructive lung disease
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14
Q

What are the appropriate investigations for aortic dissection?

A

o Bloods - FBC, X-match 10 units of blood, U&E, clotting screen

o CXR - widened mediastinum

o ECG - often NORMAL -> if the ostia of the right coronary artery is compromised you may get signs of: left ventricular hypertrophy, inferior MI

o CT Thorax - shows false lumen

o Echocardiography

o Cardiac catheterisation and aortography

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15
Q

What is the diagnosis from this CT?

A

Stanford Type A/Ascending Aortic Dissection

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16
Q

What is the diagnosis from this CT?

A

Stanford Type B/Descending Aortic Dissection

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17
Q

Define aortic regurgitation.

A

Reflux of blood from the aorta into the left ventricle during diastole.

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18
Q

What are the risk factors for aortic regurgitation?

A

o Aortic valve leaflet abnormalities or damage -> bicuspid aortic valve, infective endocarditis, rheumatic fever, trauma

o Aortic root/ascending aorta dilatation -> systemic hypertension, aortic dissection, aortitis, arthritides (e.g. rheumatoid arthritis, seronegative arthritides), connective tissue disease (e.g. Marfan’s, Ehlers-Danlos), pseudoxanthoma elasticum, oteogenesis imperfecta

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19
Q

What are the symptoms of chronic aortic regurgitation?

A

Initially ASYMPTOMATIC

Later on, the patient may develop symptoms of heart failure (e.g. exertional dyspnoea, orthopnoea, fatigue)

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20
Q

What are the symptoms of severe acute aortic regurgitation?

A

Sudden cardiovascular collapse -> left ventricle cannot adapt to the rapid increase in end-diastolic volume

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21
Q

What are the signs of aortic regurgitation on examination?

A

Collapsing (water-hammer) pulse

Wide pulse pressure

Thrusting and heaving displaced apex beat

Early diastolic murmur over the aortic valve region - maybe an ejection systolic murmur because of increased flow across the valve

Austin Flint mid-diastolic murmur (only is severe AR) - heard over the apex due to turbulent reflux hitting the anterior cusp of the mitral valve causing a physiological mitral stenosis

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22
Q

What are the appropriate investigations fro aoritic regurgitation?

A

o CXR -> cardiomegaly, dilatation of ascending aorta, pulmonary oedema (if accompanied by left heart failure)

o ECG - > may show left ventricular hypertrophy = deep S in V1/2, tall R in V5/6, inverted T waves in lead I, aVL, V5/6, left axis deviation

o Echocardiogram -> may show underlying cause (e.g. aortic root dilatation, bicuspid aortic valve) or effects of aortic regurgitation

o Doppler echocardiogram -> show AR and indicate severity

o Cardiac catheterisation with angiography -> if uncertainty about the functional state of the ventricle or the presence of coronary artery disease

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23
Q

Define aortic stenosis.

A

Narrowing of the left ventricular outflow at the level of the aortic valve.

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24
Q

What are the causes of aortic stenosis?

A

Secondary to rheumatic heart disease (MOST COMMON WORLDWIDE)

Calcification of a congenital bicuspid aortic valve

Calcification/degeneration of a tricuspid aortic valve in the elderly

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25
Q

What are the presenting symptoms of aortic stenosis?

A

May be ASYMPTOMATIC initially

Angina (due to increased oxygen demand of the hypertrophied left ventricle)

Syncope or dizziness on exercise (due to outflow obstruction)

Symptoms of heart failure (e.g. dyspnoea, orthopnoea)

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26
Q

What are the signs of aortic stenosis on examination?

A

Narrow pulse pressure

Slow-rising pulse

Thrill in the aortic area (only if severe)

Forceful sustained thrusting undisplaced apex beat

Ejection systolic murmur at the aortic area, radiating to the carotid artery

Second heart sound may be softened or absent (due to calcification)

A bicuspid valve may produce an ejection click

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27
Q

What are the appropriate investigations stenosis?

A

o ECG -> LBBB, signs of left ventricular hypertrophy = deep S in V1/2, tall R in V5/6, inverted T waves in I, aVL and V5/6, left axis deviation

o CXR -> post-stenotic enlargement of ascending aorta, calcification of aortic valve

o Echocardiogram -> structural changes of the valves and level of stenosis, estimation of aortic valve area and pressure gradient across the valve in systole, left ventricular function

o Cardiac angiography -> differentiation from other causes of angina (e.g. MI)

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28
Q

What are the signs of left ventricular hypertrophy?

A

Deep S in V1/2

Tall R in V5/6

Inverted T waves in I, aVL and V5/6

Left axis deviation

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29
Q

Define arterial ulcer.

A

A localised area of damage and breakdown of skin due to inadequate arterial blood supply

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30
Q

What are the risk factors for arterial ulcers?

A

Coronary heart disease

History of stroke or TIA

Diabetes mellitus

Peripheral arterial disease (e.g. intermittent claudication)

Obesity and immobility

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31
Q

What are the presenting symptoms of an arterial ulcer?

A

NIGHT PAIN - hallmark of arterial ulcers -> pain is worse when supine (because arterial blood flow is further reduced when supine) -> often patients combat this by dangling the affected leg off the end of the bed

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32
Q

What are the signs of arterial ulcers examination?

A

Punched-out, elliptical appearance

Hairlessness

Pale skin

Absent pulses

Nail dystrophy

Wasting of calf muscles

Ulcer base contains grey, granulation tissue

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33
Q

What are the appropriate investigations for arterial ulcers?

A

o Duplex ultrasonography of lower limbs -> assess patency of arteries and potential for revascularisation or bypass surgery

o Anti-brachial Pressure Index (ABPI)

o Percutaneous angiography

o ECG

o Bloods -> fasting serum lipids, fasting blood glucose and HbA1c (diabetes is a major risk factor), FBC (anaemia worsens the ischaemia)

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34
Q

Define AF.

A

Rapid, chaotic and ineffective atrial electrical conduction.

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35
Q

What are the categories of AF?

A

Permanent

Persistent

Paroxysmal

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36
Q

What are the causes of AF?

A

o Systemic causes = thyrotoxicosis, hypertension, pneumonia, alcohol

o Heart causes = mitral valve disease, ischaemic heart disease, rheumatic heart disease, cardiomyopathy, pericarditis, sick sinus syndrome, atrial myxoma

o Lung causes = bronchial carcinoma, PE

o No identifiable cause

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37
Q

What are the presenting symptoms of AF?

A

Often ASYMPTOMATIC

Palpitations

Syncope (if low output)

Symptoms of the cause of AF

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38
Q

What are the signs of AF on examination?

A

Irregularly irregular pulse

Difference in apical beat and radial pulse

Check for signs of thyroid disease and valvular disease

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39
Q

What are the appropriate investigations for AF?

A

o ECG - uneven baseline with absent p waves, irregular intervals between QRS complexes

o Bloods - cardiac enzymes, TFT, lipid profile, U&Es, Mg2+ and Ca2+ (last 3 due to increased risk of digoxin toxicity with hypokalaemia, hypomagnesaemia and hypercalcaemia)

o Echocardiogram - mitral valve disease, left atrial dilatation, left ventricular dysfunction, structural abnormalities

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40
Q

What is treatment for AF?

A

o FIRST treat any REVERSIBLE causes (e.g. thyrotoxicosis, chest infection)

o Rhythm control

  • if > 48 hrs since onset of AF = anti-coagulate for 3-4 weeks before attempting cardioversion
  • if < 48 hrs since onset of AF = DC cardioversion (2 x 100 J, 1 x 200 J) or chemical cardioversion: flecainide or amiodarone
  • prophylaxis against AF = sotalol, amiodarone, flecainide, consider pill-in-the-pocket (single dose of a cardioverting drug (e.g. flecainide) for patients with paroxysmal AF) strategy for suitable patients

o Rate control

  • Chronic (Permanent) AF = control ventricular rate with digoxin, verapamil, beta-blockers and aim for ventricular rate of 90 bpm

o Stroke risk stratifcation = low risk patients = aspirin and high risk patients = warfarin (based on the CHADS-Vasc score)

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41
Q

What is the CHADS-Vasc Score?

A
  • working out risk factors for a stroke
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42
Q

What are the possible complications of AF?

A

o Thromboembolism - embolic stroke risk of 4% per year and risk is increased with left atrial enlargement or left ventricular dysfunction

o Worsening of existing heart failure

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43
Q

Define cardiomyopathy.

A

Primary disease of the myocardium which can be dilated, hypertrophic or restrictive.

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44
Q

What is the cause of the majority of cardiomyopathies?

A
  • idiopathic
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45
Q

What are the risk factors for dilated cardiomyopathy?

A

Post-viral myocarditis

Alcohol

Drugs (e.g. doxorubicin, cocaine)

Familial

Thyrotoxicosis

Haemochromatosis

Peripartum

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46
Q

What are the risk factors for hypertrophic cardiomyopathies?

A
  • genetics -> up tp 50% are genetic
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47
Q

What are the risk factors for restrictive cardiomyopathies?

A

Amyloidosis

Sarcoidosis

Haemochromatosis

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48
Q

What are the presenting symptoms of dilated cardiomyopathy?

A

Symptoms of heart failure

Arrhythmias

Thromboembolism

Family history of sudden death

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49
Q

What are the presenting symptoms of hypertrophic cardiomyopathy?

A

Usually NO SYMPTOMS

Syncope

Angina

Arrhythmias

Family history of sudden death

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50
Q

What are the presenting symptoms of restrictive cardiomyopathy?

A

Dyspnoea

Fatigue

Arrhythmias

Ankle or abdominal swelling

Family history of sudden death

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51
Q

What are the signs of dilated cardiomyopathy on examiation?

A

Raised JVP

Displaced apex beat

Functional mitral and tricuspid regurgitations

Third heart sound

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52
Q

What are the signs of hypertrophic cardiomyopathy on examination?

A

Jerky carotid pulse

Double apex beat

Ejection systolic murmur

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53
Q

What are the signs of restrictive cardiomyopathy on examination?

A
  • Raised JVP = Kussmaul Sign - paradoxical rise in JVP on inspiration due to limited ventricle filling
  • Third heart sound
  • Ascites
  • Ankle oedema
  • Hepatomegaly
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54
Q

What are the appropriate investigations for cardiomyopathy?

A

o CXR = Cardiomegaly, Heart failure

o ECG = Non-specific ST changes, Conduction defects, Arrhythmias

  • Hypertrophic = left-axis deviation, signs of left ventricular hypertrophy, Q waves in inferior and lateral leads
  • Restrictive = low voltage complexes

o Echocardiography

  • Dilated = dilated ventricles with global hypokinesia
  • Hypertrophic = ventricular hypertrophy (asymmetrical septal hypertrophy)
  • Restrictive = non-dilated non-hypertrophied ventricles, atrial enlargement, preserved systolic function, diastolic dysfunction, granular or sparkling appearance of myocardium in amyloidosis

o Cardiac Catheterisation

o Endomyocardial Biopsy

o Pedigree or Genetic Analysis

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55
Q

Define constrictive pericarditis.

A

Chronic inflammation of the pericardium with thickening and scarring. It limits the ability of the heart to function normally.

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56
Q

What are the risk factors for constrictive pericarditis?

A

Idiopathic

Virus

TB

Mediastinal irradiation

Post-surgical

Connective tissue disease

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57
Q

Why is constrictive pericarditis underdiagnosed?

A
  • difficult to distinguish it from restrictive cardiomyopathy and other causes of right heart failure
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58
Q

What are the presenting signs and symptoms of constrictive pericarditis?

A

o Gradual-onset of symptoms -> early symptoms and signs may be very subtle whereas advanced would be jaundice, cachexia, muscle wasting

o Right Heart Failure Signs = dyspnoea, peripheral oedema, raised JVP, Kussmaul’s sign (paradoxical rise in JVP on inspiration), pulsatile hepatomegaly

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59
Q

What are the appropriate investigations for constrictive pericarditis?

A

o CXR - may show calcification of the pericardium

o Echocardiogram - usually diagnostic and helps distinguish from restrictive cardiomyopathy

o MRI/CT - allows assessment of thickness of pericardium

o Pericardial biopsy - may be indicated (especially if suspected infective cause)

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60
Q

Define DVT?

A

Formation of a thrombus within the deep veins (most commonly in the calf or thigh).

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61
Q

What are the risk factors for DVT’s?

A

Combined oral contraceptive pill

Post-surgery

Prolonged immobility

Obesity

Pregnancy

Dehydration

Smoking

Polycythaemia

Thrombophilia (e.g. protein C deficiency)

Malignancy

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62
Q

What are the presenting symptoms of a DVT?

A
  • swollen limb
  • often painless
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63
Q

What are the signs of DVT’s on examination?

A

o Local erythema, warmth and swelling

o Measure the leg circumference

o Varicosities (swollen/tortuous vessels)

o Skin colour changes

o Homan’s Sign - forced passive dorsiflexion of the ankle causes deep calf pain

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64
Q

What should be carried out if there is a suspected DVT?

A

o Wells Score -> score >2 = high risk of a PE
o examine for a PE - RR, sats, HR

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65
Q

What are the appropriate investigations for a DVT?

A

o Doppler Ultrasound = GOLD STANDARD

o Impedance Plethysmography - changes in blood volume results in changes of electrical resistance

o Bloods - D-dimer, thrombophilia screen if indicated

o If PE suspected = ECG, CXR, ABG

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66
Q

What is the treatment plan for a DVT?

A

o Anti-coagulation - heparin whilst waiting for warfarin to increase INR to the target range of 2-3 -> if not extended above the knee anticoagulated for 3 months but if they do it is 6 months

  • recurrent DVTs require long-term warfarin

o IVC filter - may be used if anticoagulation is contraindicated and there is a risk of embolisation

o Prevention - graduated compression stockings, mobilisation, prophylactic heparin (if high risk e.g. hospitalised patients)

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67
Q

What are the possible complications of DVT’s?

A
  • PE
  • Venous infarction (phlegmasia cerulea dolens)
  • Thrombophlebitis (results from recurrent DVT)
  • Chronic venous insufficiency
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68
Q

Define gangrene.

A

Tissue necrosis, either wet with superimposed infection, dry or gas gangrene.

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69
Q

Define necrotising fasciitis.

A

A life-threatening infection that spreads rapidly across fascial planes.

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70
Q

What are the risk factors for gangrene/necrotising fasciitis?

A

Diabetes

Peripheral vascular disease

Obesity

Leg ulcers

Malignancy

Immunosuppression/Steroid use

Puncture/surgical wounds

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71
Q

What are the presenting symptoms of gangrene?

A

Pain

Discolouration of affected area

Often affects extremities or areas subject to high pressure

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72
Q

What are the presenting symptoms of necrotising fasciitis?

A

Pain - often seems SEVERE and out of proportion to the apparent physical signs

Predisposing event (e.g. trauma, ulcer, surgery)

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73
Q

What are the signs of gangrene on examination?

A

o Painful area = erythematous region around gangrenous tissue

o Gangrenous tissue = black because of haemoglobin break down products

o Wet Gangrene - tissue becomes boggy with associated pus and a strong odour caused by the activity of anaerobes

o Gas Gangrene - spreading infection and destruction of tissues causes overlying oedema, discolouration and crepitus (due to gas formation by the infection)

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74
Q

What are the signs of necrotising fasciitis on examination?

A

o Area of erythema and oedema

o Haemorrhagic blisters may be present

o Signs of systemic inflammatory response and sepsis (high/low temperature, tachypnoea, hypotension)

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75
Q

What are the appropriate investigations for gangrene and necrotising fasciitis?

A

o Bloods - FBC, U&Es, glucose, CRP and blood culture

o Wound Swab, Pus/Fluid Aspirate - MC&S

o X-ray of affected area - may show gas produced in gas gangrene

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76
Q

Define 1st degree AV block.

A

Prolonged conduction through the AV node.

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77
Q

Define 2nd degree AV block, Mobitz type I.

A

Progressive prolongation of AV node conduction culminating in one atrial impulse failing to be conducted through the AV node, before the cycle starts again.

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78
Q

Define 2nd degree AV block, Mobitz type II.

A

Intermittent or regular failure of conduction through the AV node.

  • also defined by the number of normal conductions per failed or abnormal one (e.g. 2:1 or 3:1)
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79
Q

Define 3rd degree/complete AV block.

A

No relationship between atrial and ventricular contraction. Failure of conduction through the AV node leads to ventricular contraction generated by a focus of depolarisation within the ventricle.

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80
Q

What are the presnting symptoms of 1st degree heart block?

A
  • asymptomatic
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81
Q

What are the presenting symptoms of 2nd degree heart block, Mobitz type II?

A
  • usually asymptomatic
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82
Q

What are the presenting symptoms of 2nd degree heart block, Mobitz type II and complete?

A

o may cause Stokes-Adams Attacks (syncope caused by ventricular asystole)

o may also cause dizziness, palpitations, chest pain and heart failure

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83
Q

What are the signs of heart block on examination?

A

o Often Normal

o Check for signs of a potential cause of heart block

o Complete Heart Block = slow large volume pulse, JVP may show cannon a waves, signs of reduced cardiac output (e.g. hypotension, heart failure)

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84
Q

What are the appropriate investigations for heart block?

A

o ECG - GOLD STANDARD

  • First degree = fixed prolonged PR interval (> 0.2 s)
  • Mobitz type I = progressively prolonged PR interval, culminating in a P wave that is NOT followed by a QRS complex.
  • Mobitz type II = intermittently a P wave is NOT followed by a QRS. with a possible pattern (e.g. 2:1 or 3:1)
  • Complete heart block = no relationship between P waves and QRS complexes. If QRS is initiated in the: Bundle of His = narrow complex or more distally = wide complex and slow rate (~ 30 bpm)

o CXR - cardiac enlargement, pulmonary oedema

o Bloods - TFTs, digoxin level, cardiac enzymes, troponin

o Echocardiogram - wall motion abnormalities, aortic valve disease, vegetations

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85
Q

What is the treatment for heart block?

A

o Chronic block = Permanent pacemaker is recommended in complete heart block, advanced Mobitz type II, symptomatic Mobitz type I

o Acute Block = if associated with clinical deterioration use IV atropine and consider temporary (external) pacemaker

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86
Q

What are the possible complications of heart block?

A

Asystole

Cardiac arrest

Heart failure

Complications of any pacemaker inserted

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87
Q

Define hypertension.

A

Systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions.

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88
Q

Define malignant hypertension.

A

BP > 200/130 mm Hg

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89
Q

What are the causes of hypertension?

A

o Primary = .90% of cases

  • essential or idiopathic hypertension

o Secondary

  • Renal = renal artery stenosis, chronic glomerulonephritis, chronic pyelonephritis, polycystic kidney disease, chronic renal failure
  • Endocrine = diabetes mellitus, hyperthyroidism, Cushing’s syndrome, Conn’s syndrome, hyperparathyroidism, phaeochromocytoma, congenital adrenal hyperplasia, acromegaly
  • Cardiovascular = coarctation of the aorta, increased intravascular volume
  • Drugs = sympathomimetics, corticosteroids, COCP
  • Pregnancy = pre-eclampsia
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90
Q

What are the presenting symptoms of hypertension?

A

Often ASYMPTOMATIC

Symptoms of complications

Symptoms of the cause

91
Q

What are the presenting symptoms of malignant hypertension?

A

Scotomas (visual field loss)

Blurred vision

Headache

Seizures

Nausea and vomiting

Acute heart failure

92
Q

What are the signs of hypertension on examination?

A

o Blood pressure should be measured on 2-3 different occasions before diagnosing hypertension - lowest reading should be recorded

o Examination may reveal information about causes

  • radiofemoral delay = co-arctation of the aorta distal to the left subclavian artery
  • renal artery bruit = renal artery stenosis
  • fundoscopy to detect hypertensive retinopathy
93
Q

What are the appropriate investigations for hypertension?

A

o Bloods = U&Es, glucose, lipids

o Urine dipstick = blood and protein (e.g. if glomerulonephritis)

o ECG = may show signs of left ventricular hypertrophy or ischaemia

o Ambulatory blood pressure monitoring = excludes white coat hypertension

o Other investigations may be performed if a secondary cause of the hypertension is suspected

94
Q

What are the categories for hypertension treatment?

A

o conservative = stop smoking, lose weight, reduce alcohol, reduce dietary sodium

o medical

95
Q

What is the treatment of hypertension?

A
96
Q

What is the target BP for a non-diabetic with hypertension?

A

< 140/90 mmHg

97
Q

What is the target BP for a diabetic, without proteinuria, with hypertension?

A

< 130/80 mmHg

98
Q

What is the target BP for a diabetic, with proteinuria, with hypertension?

A

< 125/75 mmHg

99
Q

What is the treatment for acute malignant hypertension?

A

o IV beta-blocker (e.g. esmolol)

o Labetolol

o Hydralazine sodium nitroprusside

o CAUTION: avoid rapid lowering of blood pressure because it can cause cerebral infarction - autoregulatory mechanisms within the brain for regulating blood flow will cause vasoconstriction of the vessels in the brain when blood pressure is very high and lowering the blood pressure too rapidly doesnt allow for adjustment

100
Q

What are the possible complications of hypertension?

A

Heart failure

Coronary artery disease

Cerebrovascular accidents

Peripheral vascular disease

Emboli

Hypertensive retinopathy

Renal failure

Hypertensive encephalopathy

Posterior reversible encephalopathy syndrome (PRES)

Malignant hypertension

101
Q

Define infective endocarditis.

A

Infection of intracardiac endocardial structures (mainly heart valves).

102
Q

What are the risk factors for infective endocarditis?

A

Abnormal valves (e.g. congenital, calcification, rheumatic heart disease)

Prosthetic heart valves

Turbulent blood flow

Recent dental work/poor dental hygiene

103
Q

What are the presenting symptoms of infective endocaritis?

A

o Fever with sweats/chills/rigors - might be relapsing and remitting

o Malaise

o Arthralgia

o Myalgia

o Confusion

o Skin lesions

o Ask about recent dental surgery or IV drug use

104
Q

What are the signs of infective endocarditis on examination?

A

o Pyrexia

o Tachycardia

o Signs of anaemia

o New regurgitant murmur or muffled heart sounds

o Frequency of heart murmurs: Mitral > Aortic > Tricuspid > Pulmonary

o Splenomegaly

o Vasculitic Lesions - Roth spots on retina, petechiae on pharyngeal and conjunctival mucosa, Janeway lesions, Osler’s nodes, splinter haemorrhages

105
Q

What are the appropriate investigations for infective endocarditis?

A

o Bloods - FBC - high neutrophils, normocytic anaemia, high ESR/CRP, U&Es

o Urinalysis - microscopic haematuria, proteinuria

o Blood culture

o Echocardiography = transthoracic or transoesophageal (produces better image)

o Duke’s Classification - a method of diagnosing infective endocarditis based on the findings of the investigations and the symptoms/signs

106
Q

What is the treatment for infective endocarditis?

A

o Antibiotics for 4-6 weeks

o On clinical suspicion = EMPIRICAL TREATMENT -> benzylpenicillin, gentamicin

o Surgery - urgent valve replacement may be needed if there is a poor response to antibiotics

107
Q

What are the possible complications of infective endocarditis?

A

Valve incompetence

Intracardiac fistulae or abscesses

Aneurysm

Heart failure

Renal failure

Glomerulonephritis

Arterial emboli from the vegetations shooting to the brain, kidneys, lungs and spleen

108
Q

Define ischaemic heart disease.

A

Characterised by decreased blood supply to the heart muscle resulting in chest pain (angina). May present as stable angina or acute coronary syndrome.

109
Q

How can acute coronary syndrome be further subdivided?

A

Unstable angina - chest pain at rest due to ischaemia but without cardiac injury

NSTEMI

STEMI - ST elevation with transmural infarction

110
Q

What are the risk factors for IHD?

A

Male

Diabetes mellitus

Family history

Hypertension

Hyperlipidaemia

Smoking

111
Q

Define mitral regurgitation.

A

Retrograde flow of blood from left ventricle to left atrium during systole.

112
Q

What are the causes of mitral regurgitation?

A

o Caused by mitral valve damage or dysfunction, which, in turn could be caused by any of the following:

  • Rheumatic heart disease (MOST COMMON)
  • Infective endocarditis
  • Mitral valve prolapse
  • Papillary muscle rupture or dysfunction
  • Chordal rupture and floppy mitral valve associated with connective tissue disease (e.g. Ehlers-Danlos syndrome, Marfan’s syndrome)
113
Q

What are the presenting symptoms of mitral regurgitation?

A

o Acute MR - may present with symptoms of left ventricular failure

o Chronic MR - may be asymptomatic or present with exertional dyspnoea, palpitations if in AF and fatigue

o Mitral Valve Prolapse - asymptomatic or atypical chest pain or palpitations

114
Q

What are the signs of mitral regurgitation on examination?

A

o Pulse may be irregularly irregular (if in AF)

o Laterally displaced apex beat with thrusting (due to left ventricular dilation)

o Pansystolic murmur - loudest at apex beat and radiating to the axilla

o Soft S1

o S3 may be heard due to rapid ventricular filling in early diastole

o Signs of left ventricular failure in acute mitral regurgitation

115
Q

What are the signs of mitral valve prolapse on examination?

A

Mid-systolic click

Late systolic murmur

The click moves towards S1 when standing and away when lying down

116
Q

What are the appropriate investigations for mitral regurgitation?

A

o ECG = normal or may show AF or p mitrale (bifid p wave in lead II) indicating left atrial hypertrophy

o CXR

  • acute mitral regurgitation may produce signs of left ventricular failure
  • chronic mitral regurgitation shows left atrial enlargement, cardiomegaly (due to LV dilation), mitral valve calcification (if rheumatic heart disease is the cause)

o Echocardiography - performed every 6-12 months in moderate-severe MR to allows assessment of LV ejection fraction and end-systolic dimension

117
Q

Define mitral stenosis.

A

Mitral valve narrowing causing obstruction to blood flow from the left atrium to the left ventricle.

118
Q

What are the causes of mitral stenosis?

A

o MAIN CAUSE: Rheumatic Heart Disease (90% of cases)

o Rare causes of mitral stenosis = congenital mitral stenosis, SLE, rheumatoid arthritis, endocarditis, atrial myxoma

119
Q

What are the presenting symptoms of mitral stenosis?

A

o May be asymptomatic

o Fatigue

o SOBOE

o Orthopnoea

o Palpitations (related to AF)

o Rare symptoms = cough, haemoptysis, hoarseness caused by compression of left recurrent laryngeal nerve by an enlarged left atrium

120
Q

What are the signs of mitral stenosis on examination?

A

o Peripheral cyanosis

o Malar flush

o Irregularly irregular pulse (if in AF)

o Apex beat undisplaced and tapping

o Parasternal heave (due to right ventricular hypertrophy secondary to pulmonary hypertension)

o Mid-diastolic murmur

o Loud S1 with opening snap

o Pulmonary oedema (if decompensated)

121
Q

What are the appropriate investigations for mitral stenosis?

A

o ECG = may be normal or may see p mitrale (broad bifid p wave caused by left atrial hypertrophy) or AF

  • evidence of right ventricular hypertrophy may be seen if there is severe pulmonary hypertension

o CXR = left atrial enlargement, cardiac enlargement, pulmonary congestion, mitral valve calcification (occurs in rheumatic cases)

o Echocardiography - assesses functional and structural impairments

o Cardiac Catheterisation - measures severity of heart failure

122
Q

Define myocarditis.

A

Acute inflammation and necrosis of cardiac muscle (myocardium).

123
Q

What are the causes of myocarditis?

A

o Usually idiopathic

o Viruses = coxsackie B, EBV, CMV, adenovirus, influenza

o Bacteria = post-streptococcal, TB, diphtheria

o Fungal = candidiasis

o Protozoal = trypanosomiasis (Chagas disease)

o Helminths = trichinosis

o Non-infective = systemic: SLE, sarcoidosis, polymyositis or hypersensitivity myocarditis: sulphonamides

o Drugs = chemotherapy agents (e.g. doxorubicin, streptomycin)

o Others = cocaine, heavy metals, radiation

124
Q

What are the presenting sympotoms of myocarditis?

A

o Prodromal flu-like illness with fever, malaise, fatigue, lethargy

o Breathlessness (due to pericardial effusion/myocardial dysfunction)

o Palpitations

o Sharp chest pain (suggesting there is also pericarditis)

125
Q

What are the signs of myocarditis on examination?

A

Signs of pericarditis

Signs of complications (e.g. heart failure, arrhythmia)

126
Q

What are the appropriate investigations for myocarditis?

A

o Bloods = FBC (raised WCC if infective cause), U&E, ESR/CRP (raised), cardiac enzymes (raised), tests to identify cause (e.g. viral/bacterial serology, ANA, TFT)

o ECG = non-specific T wave and ST changes or widespread saddle-shaped ST elevation signalling pericarditis

o CXR = may be normal but often shows cardiomegaly

o Pericardial Fluid Drainage = measure glucose, protein, cytology, culture and sensitivity and helps identify causative organism

o Echocardiography = assesses systolic/diastolic function, wall motion abnormalities, pericardial effusions

o Myocardial Biopsy = rarely required

127
Q

Define pericarditis.

A

Inflammation of the pericardium.

-can be acute, subacute or chronic

128
Q

What are the risk factors of pericarditis?

A

o Idiopathic

o Infective - coxsackie B, echovirus, mumps, streptococci, fungi, staphylococci,

TB

o Connective tissue disease (e.g. sarcoidosis, SLE, scleroderma)

o Post-MI (within 24-72 hrs of MI - occurs in up to 20% of patients)

o Dressler’s Syndrome - pericarditis occurring weeks/months after acute MI

o Malignancy - lung, breast, lymphoma, leukaemia, melanoma

o Radiotherapy

o Thoracic surgery

o Drugs (e.g. hydralazine, isoniazid)

129
Q

What are the presenting symptoms of pericarditis?

A

o Chest pain - sharp and central but may radiate to the neck or shoulders

  • worse when coughing and deep inspiration (pleuritic pain) and relieved by sitting forward

o Dyspnoea

o Nausea

130
Q

What are the signs of pericarditis on examination?

A

o Fever

o Pericardial friction rub - heard best at lower left sternal edge, with patient leaning forward during expiration

o Heart sounds may be faint due to a pericardial effusion

o Cardiac Tamponade signs = Beck’s Triad = raised JVP, low BP, muffled heart sounds

o Tachycardia

o Pulsus paradoxus = an abnormally large decrease in SBP (> 10 mm Hg drop) and pulse wave amplitude during inspiration

o Constrictive Pericarditis signs = Kussmaul’s sign, pulsus paradoxus, hepatomegaly, ascites, oedema, pericardial knock (due to rapid ventricular filling), AF

131
Q

What are the appropriate investigations for pericarditis?

A

o ECG = widespread saddle-shaped ST elevation

o Echocardiogram - assesses pericardial effusion and cardiac function

o Bloods = FBC, U&Es, ESR/CRP, cardiac enzymes (usually normal)

o Other investigations for cause = blood cultures, ASO titres, ANA, rheumatoid factor

o CXR = usually normal but may be globular if there is a pericardial effusion

132
Q

What is the treatment for pericarditis?

A

o Acute - cardiac tamponade is treated with emergency pericardiocentesis

o Medical - treat underlying cause plus NSAIDs for pain and fever relief

o Recurrent - low-dose steroids, immunosuppressants, colchicine

o Surgical - pericardiectomy is performed in cases of constrictive pericarditis

133
Q

What are the possible complications of pericarditis?

A

Pericardial effusion

Cardiac tamponade

Cardiac arrhythmias

134
Q

Define peripheral vascular disease.

A

Occurs due to atherosclerosis causing stenosis of arteries via a multifactorial process involving modifiable and non-modifiable risk factors.

135
Q

What is the cause of peripheral vascular disease and what are the risk factors?

A

o Atherosclerosis

  • Smoking
  • Diabetes
  • Hypertension
  • Hyperlipidaemia
  • Physical inactivity
  • Obesity
136
Q

What are the types of peripheral vascular disease?

A

o Intermittent claudication - calf pain on exercise

o Critical limb ischaemia - pain at rest

o Acute limb ischaemia - a sudden decrease in arterial perfusion in a limb, due to thrombotic or embolic causes

o Arterial ulcers

o Gangrene

137
Q

What are the presenting symptoms of intermittent claudication peripheral vascular disease?

A

o Cramping pain in the calf, thigh or buttock after walking for a given distance (claudication distance) and relieved by rest

  • Calf claudication = femoral disease
  • Buttock claudication = iliac disease
138
Q

What are the presenting symptoms of critical limb ischaemia peripheral vascular disease?

A

Ulcers

Gangrene

Rest pain

Night pain (relieved by dangling leg over the edge of the bed)

139
Q

What are the presenting symptoms of Leriche syndrome peripheral vascular disease?

A

Buttock claudication

Impotence

Absent/weak distal pulses

140
Q

What are the signs of peripheral vascular disease on examination?

A

o Acute Limb Ischaemia = 6 Ps

  • Pain
  • Pale
  • Pulseless
  • Paralysis
  • Paraesthesia
  • Perishingly Cold

o Other symptoms = atrophic skin, hairless, punched-out ulcers (often painful), colour change when raising leg (to Buerger’s angle)

141
Q

What are the appropriate investigations for peripheral vascular disease?

A

o Full cardiovascular risk assessment = BP, FBC (anaemia will worsen ischaemia), fasting blood glucose, lipid levels, ECG (check for pre-existing coronary artery disease), thrombophilia screen (patients < 50 yrs)

o Colour Duplex Ultrasound = FIRST-line - shows site and degree of stenosis

o MRI/CT = assesses extent and location of stenoses

o ABPI (Ankle-Brachial Pressure Index) = marker of cardiovascular disease ->

ABPI < 0.8 = do NOT apply a pressure bandage because this will worsen ischaemia

142
Q

Define pulmonary hypertension.

A

An increase in mean pulmonary arterial pressure which can be caused by or associated with a wide variety of other conditions.

143
Q

What are the causes of pulmonary hypertension?

A

Idiopathic

Problems with smaller branches of the pulmonary arteries

Left ventricular failure

Lung disease (e.g. COPD, interstitial lung disease)

Thromboses/Emboli in the lungs

144
Q

What are the presnting symptoms of pulmonary hypertension?

A

o Progressive breathlessness

o Weakness/tiredness

o Exertional dizziness and syncope

o Late stage = Oedema and Ascites

o Angina and tachyarrhythmia

145
Q

What are the signs of pulmonary hypertension on examination?

A

Right ventricular heave

Loud pulmonary second heart sound

Murmur - pulmonary regurgitation

Tricuspid regurgitation

Raised JVP

Peripheral oedema

Ascites

146
Q

What are the appropriate investigation for pulmonary hypertension?

A

o CXR - exclude other lung diseases

o ECG - right ventricular hypertrophy and strain

o Pulmonary function tests

o LFTs - liver damage –> portal hypertension

o Lung biopsy - interstitial lung disease

o Echocardiography - assess right ventricular function

o Right heart catheterisation - directly measure pulmonary pressure and confirm the diagnosis

147
Q

Define supraventricular tachycardia.

A

A regular narrow-complex tachycardia (> 100 bpm) with no p waves and a supraventricular origin.

  • AF technically counts as a type of SVT
  • However, SVT generally refers to: AVNRT and AVRT
148
Q

What is AVNRT?

A

A localised re-entry circuit forms around the AV node.

149
Q

What is AVRT?

A

A re-entry circuit forms between the atria and ventricles due to the presence of an accessory pathway (Bundle of Kent - Wolff-Parkinson-White syndrome).

150
Q

What are the risk factors for supraventricular tachycardias?

A

Nicotine

Alcohol

Caffeine

Previous MI

Digoxin toxicity

151
Q

What are the presenting symptoms of supraventicular tachycardias?

A

May have minimal symptoms or may present with syncope

Symptoms vary depending on rate and duration of SVT

Palpitations

Light-headedness

Abrupt onset and termination of symptoms

Other symptoms: fatigue, chest discomfort, dyspnoea, syncope

152
Q

What are the signs of supraventricular tachycardias on examination?

A

o AVNRT - normal except tachycardia

o Wolff-Parkinson-White - tachycardia and secondary cardiomyopathy (S3 gallop, RV heave, displaced apex beat)

153
Q

What are the appropriate investigations for supraventricular tachycardias?

A

o ECG = to differentiate between AVNRT and AVRT

  • AVNRT - appears normal
  • AVRT = delta-waves (slurred upstroke of the QRS complex)

o 24 hr ECG monitoring - will be required in patients with paroxysmal palpitations

o Cardiac Enzymes - check for features of MI (especially if there is chest pain)

o Bloods = electrolytes, TFTs, digoxin levels

o Echocardiogram - check for structural heart disease

154
Q

What is the treatment for supraventricular tachycardias?

A

o If haemodynamically unstable = DC cardioversion

o If haemodynamically stable = vagal monouevres + chemical cardioversion

  • If vagal manoeuvres fail: adenosine 6 mg bolus (can increase to 12 mg) (contraindicated in asthma as it can cause bronchospasm), verapamil 2.5 - 5 mg, atenolol, amiodarone

o If unresponsive to chemical cardioversion or tachycardia > 250 bpm or adverse signs (low BP, heart failure, low consciousness) = sedate and synchronised DC cardioversion and amiodarone

o Ongoing management of SVT

  • AVNRT = radiofrequency ablation of slow pathway, beta-blockers
  • AVRT = radiofrequency ablation
  • Sinus tachycardia = exclude secondary cause (e.g. hyperthyroidism), beta-blocker or rate-limiting CCB
155
Q

What are the possible complications of supraventricular tachycardias?

A

Haemodynamic collapse

DVT

Systemic embolism

Cardiac tamponade

156
Q

Define tricuspid regurgitation.

A

Backflow of blood from the right ventricle to the right atrium during systole.

157
Q

What are the causes of tricuspid regurgitation?

A

o Congenital = Ebstein’s anomaly (malpositioned tricuspid valve - very low down leaving a small ventricle and floppy valve), cleft valve in ostium primum

o Functional = consequence of right ventricular dilation, valve prolapse

o Rheumatic Heart Disease

o Infective Endocarditis

o Other = carcinoid syndrome, trauma, cirrhosis, iatrogenic

158
Q

What are the presenting symptoms of tricuspid regurgitation?

A

o Fatigue

o Breathlessness

o Palpitations

o Headaches

o Nausea

o Anorexia

o Epigastric pain made worse by exercise

o Jaundice

o Lower limb swelling

159
Q

What are the signs of tricuspid regurgitation on examination?

A

o Pulse = irregularly irregular if AF

o Inspection = raised JVP with giant V waves (which may oscillate the earlobes) and giant A waves may also be present

o Palpation = parasternal heave

o Auscultation = pansystolic murmur, louder on inspiration (Carvallo sign), loud P2 component of second heart sound

o Chest examination = pleural effusion, causes of pulmonary hypertension

o Abdominal examination = palpable liver, ascites

o Legs = pitting oedema

160
Q

What are the appropriate investigations for tricuspid regurgitation?

A

o Bloods = FBC, LFT, cardiac enzymes, cultures

o ECG = p pulmonale (due to right atrial hypertrophy)

o CXR = right-sided enlargement of cardiac shadow

o Echo = shows regurg and may show valve prolapse and right ventricular dilation

o Right heart catheterisation = rarely necessary but may be useful for assessing pulmonary artery pressure

161
Q

Define varicose veins.

A

Veins that become prominently elongated, dilated and tortuous, most commonly the superficial veins of the lower limbs.

162
Q

What are the cuases of varicose veins?

A

o Primary = genetic or developmental weakness in the vein wall resulting in increased elasticity, dilatation and valvular incompetence

o Secondary

  • Due to venous outflow obstruction -> pregnancy, pelvic malignancy, ovarian cysts, ascites, lymphadenopathy, retroperitoneal fibrosis
  • Due to valve damage (e.g. after DVT)
  • Due to high flow (e.g. arteriovenous fistula)
163
Q

What are the risk factors for varicose veins?

A

Age

Female

Family history

Caucasian

Obesity

164
Q

What are the presenting symptoms of varicose veins?

A

Patients may complain about the cosmetic appearance

Aching in the legs

Aching is worse towards the end of the day of after standing for long periods of time

Swelling

Itching

Bleeding

Infection

Ulceration

165
Q

What are the signs of varicose veins on examination?

A

o Inspection is done when patient is standing

o Palpation = fascial defects along the veins, cough impulse may be felt over the saphenofemoral junction, tap test (tapping over the saphenofemoral junction will lead to an impulse felt distally), palpation of a thrill or auscultation of a bruit would suggest an AV fistula

o Trendelenburg Test - legs are elevated and the veins are emptied before a hand is placed over the saphenofemoral junction, leg is put back down and filling of the veins is observed before and after the hand is released from the saphenofemoral junction a Doppler ultrasound can be used to show saphenofemoral incompetence

o Rectal or Pelvic Examination - if secondary causes are suspected

o Signs of venous insufficiency = varicose eczema, haemosiderin staining, atrophie blanche, lipodermatosclerosis, oedema, ulceration

166
Q

What are the appropriate investigations for varicose veins?

A

o Duplex Ultrasound = locates sites of incompetence or reflux and allows exclusion of DVT

167
Q

What is the treatment for varicose veins?

A

o Conservative = exercise improves skeletal muscle pump, elevation of legs at rest, support stockings

o Venous telangiectasia and reticular veins = laser sclerotherapy, microinjection sclerotherapy

o Surgical = saphenofemoral ligation, stripping of the long saphenous vein (never the short saphenous vein due to risk of sural nerve damage), avulsion of varicosities

168
Q

What are the possible complications of varicose veins?

A
  • Venous pigmentation
  • Eczema
  • Lipodermatosclerosis
  • Superficial thrombophlebitis
  • Venous ulceration
169
Q

What are the possible complications of varicose vein treatment?

A

Sclerotherapy - skin staining, local scarring

Surgery - haemorrhage, infection, recurrence, paraesthesia, peroneal nerve injury

170
Q

Define vasovagal syncope.

A

Loss of consciousness due to a transient drop in blood flow to the brain caused by excessive vagal discharge.

171
Q

What often precipitates vasovagal syncope?

A
  • Emotions (e.g. fear, severe pain, blood phobia)
  • Orthostatic stress (e.g. prolonged standing, hot weather)
172
Q

What are the presenting symptoms of vasovagal syncope?

A

Loss of consciousness lasting a short time

Patients may experience vagal symptoms (sweating, dizziness, light-headedness) before passing out

There may be some twitching of limbs during the blackout

Recovery is normally very quick

173
Q

What are the signs of vasovagal syncope on examinaton?

A

o Usually no signs

174
Q

What are the appropriate investigations for vasovagal syncope?

A

o Investigations are involved with checking for other causes of syncope

  • ECG = check for arrhythmia
  • Echocardiogram = check for outflow obstruction
  • Lying/standing blood pressure = check for orthostatic hypotension
  • Fasting blood glucose = check for DM/hypoglycaemia
175
Q

Define venous ulcers.

A

Large, shallow, sometimes painful ulcers usually found superior to the medial malleoli, caused due to incompetent valves in the lower limbs allowing venous stasis and increased pressure.

176
Q

What are risk factors for venous ulcers?

A

Obesity

Immobility

Recurrent DVT

Varicose veins

Previous injury/surgery to the leg

Age

177
Q

What are the presenting symptoms of venous ulcers?

A

o Large, shallow, relatively painless ulcer with an irregular margin situated above the medial malleoli (most of the time)

o Features of the history = varicose veins, DVT, phlebitis, fracture, trauma or surgery, family history

o Other symptoms of venous insufficiency = swelling/oedema, itching, aching

178
Q

What are the signs of venous ulcers on examination?

A

Stasis eczema

Lipodermatosclerosis (inverted champagne bottle sign if SEVERE)

Haemosiderin deposition (dark colour)

179
Q

What are the appropriate investigations for venous ulcers?

A

o ABPI = to exclude arterial ulcer -> if ABPI < 0.8 - do not apply a pressure bandage as this could worsen the ulcer

o Measure surface area of ulcer = allows monitoring of progression

o Swabs for microbiology if signs of infection

o Biopsy = if possibility of Marjolin’s ulcer

180
Q

What is the treatment for venous ulcers?

A

o Graduated compression (reduced venous stasis) - must exclude diabetes, neuropathy and PVD before this is attempted

o Debridement and cleaning

o Antibiotics - if infected

o Topical steroids - may help with surrounding dermatitis

181
Q

Define ventricular fibrillation.

A

An irregular broad-complex tachycardia that can cause cardiac arrest and sudden cardiac death.

182
Q

What are the risk factors for VF?

A

Coronary artery disease

AF

Hypoxia

Ischaemia

Pre-excitation syndrome

183
Q

What are the presenting symptoms of VF?

A

o History of: chest pain, fatigue, palpitations

o There may be known pre-existing conditions: coronary artery disease, cardiomyopathy, valvular heart disease, long QT syndrome, Wolff-Parkinson-White syndrome, Brugada syndrome

184
Q

What are the appropriate investigations for VF?

A

o ECG

o Bloods = cardiac enzymes, electrolytes (derangement can cause arrhythmias, including VF) , drug levels and toxicology screen, TFTs

o Coronary angiography - if patient survives VF, to check the integrity of coronary arteries

185
Q

What is the treatment for VF?

A

o VF requires urgent defibrillation and cardioversion

o Patients who survive need full assessment of left ventricular function, myocardial perfusion and electrophysiological stability

o Most survivors will need an implantable cardioverter defibrillator (ICD)

o Empirical beta-blockers

o Some patients may be treated with radiofrequency ablation (RFA)

186
Q

What are the possible complications of VF?

A

Ischaemic brain injury due to loss of cardiac output

Myocardial injury

Post-defibrillation arrhythmias

Aspiration pneumonia

Skin burns

DEATH/CARDIAC ARREST

187
Q

Define ventricular tachycardia.

A

A regular broad-complex tachycardia originating from a ventricular ectopic focus. The rate is usually > 120 bpm.

188
Q

What are the risk factors for VT?

A

Coronary heart disease

Structural heart disease

Electrolyte deficiencies (e.g. hypokalaemia, hypocalcaemia, hypomagnesaemia)

Use of stimulant drugs (e.g. caffeine, cocaine)

189
Q

WHat are the presenting symptoms of VT?

A

o Symptoms of ischaemic heart disease or haemodynamic compromise due to poor perfusion

  • Chest pain
  • Palpitations
  • Dyspnoea
  • Syncope
190
Q

What are the signs of VT on examination?

A

o Signs are dependent on the degree of haemodynamic instability

  • Respiratory distress
  • Bibasal crackles
  • Raised JVP
  • Hypotension
  • Anxiety
  • Agitation
  • Lethargy
  • Coma
191
Q

What are the appropriate investigations for VT?

A

o ECG = > 100 bpm, broad QRS complexes, AV dissociation -> can be difficult to distinguish between VT and SVT with aberrant conduction if in doubt, treat as a VT

o Bloods = electrolytes (derangement can cause arrhythmias), drug levels, cardiac enzymes

192
Q

What is the treatment of VT?

A

o ABC approach -> CHECK WHETHER THE PATIENT HAS A PULSE OR NOT

o Pulseless VT = follow advanced life support algorithm = unsynchronised defibrillation

o Unstable VT = reduced cardiac output -> correct electrolyte abnormalities, amiodarone, synchronised DC shock (if steps above are unsuccessful)

o Stable VT = patients who don’t experience symptoms -> correct electrolyte abnormalities, amiodarone, synchronised DC shock (if steps above are unsuccessful)

o Implantable cardioverter defibrillator (ICD) considered if:

  • sustained VT causing syncope
  • sustained VT with ejection fraction < 35%
  • previous cardiac arrest due to VT or VF
  • MI complicated by non-sustained VT
193
Q

What are the possible complications of VT?

A

Congestive cardiac failure

Cardiogenic shock

VT may deteriorate into VF

DEATH/CARDIAC ARREST

194
Q

Define Woll-Parkinson-White syndrome.

A

A congenital abnormality which can result in supraventricular tachycardias that use an accessory pathway (Bundle of Kent) - is a pre-excitation syndrome.

195
Q

What diseases are associated with WPW syndrome?

A

Congenital cardiac defects

Ebstein’s anomaly (congenital malformation of the heart characterised by displacement of septal and posterior tricuspid leaflets)

Mitral valve prolapse

Cardiomyopathies (e.g. HOCM)

196
Q

What are the presenting symptoms of WPW syndrome?

A

o Often asymptomatic - may be an incidental finding of an ECG

o Symptoms = palpitations, light-headedness, syncope

  • Paroxysmal SVT may be followed by a period of polyuria, due to atrial dilatation and release of ANP
  • Sudden death if SVT deteriorates into VF
  • Clinical features of associated cardiac defects (e.g. mitral valve prolapse, cardiomyopathy)
197
Q

What are the appropriate investigations for WPW syndrome?

A

o ECG may be normal if the conduction speed of the impulse along the accessory pathway matches the conduction speed down the bundle of His

o Classic ECG findings = short PR interval, broad QRS complex, slurred upstroke producing a delta wave

o Patient may be in SVT (AVRT)

o Bloods - check for other causes of arrhythmia

o Echocardiogram - check for structural heart defects

198
Q

Define rheumatic fever.

A

A non-contagious acute fever, caused by streptococcal infection, marked by inflammation and pain in the joints, usually affects the young.

199
Q

What are the risk factors for rheumatic fever?

A

o Family history

o Enviromental factors

o Particular type of strep infection

200
Q

What are the presenting symptoms of rheumatic fever?

A

o Chest pain

o Rapid fluttering or pounding chest palpitations

o Lethargy or fatigue

o Nosebleeds

o Stomach pain

o Painful or sore joints in the wrists, elbows, knees, and ankles

o Pain in one joint that moves to another joint

o Red, hot, swollen joints

o Shortness of breath

o Fever

sweating

vomiting

a decrease in attention span

outbursts of crying or inappropriate laughter

201
Q

What are the clinical signs of rheumatic fever on examination?

A

o Small, painless nodules under the skin

o A flat/slightly raised ragged rash

o Jerky, uncontrollable movements of the hands, feet and face

202
Q

What are the appropriate investigations for rheumatic fever?

A

o Bloods = FBC, ESR/CRP

o Throat/Blood cultures = check for strep

o Upper/Lower Limb Nervous examination

o Echo

o ECG

203
Q

What are the possible complications of rheumatic fever?

A

o Aortic stenois

o Aortic regurgitation

o Heart muscle damage

o AF

o Heart failure

o If left untreated for a long period of time = Stroke, Long-term heart damage, Death

204
Q

What are the indications for a coronary angiography?

A

o MI

o Unstable angina

o Chronic stable angina

o Abnormal stress test

o Ventricular arrythmias

o Left ventricular dysfunction

o Valvular disease

o Pre-op coronary assessment for cardiovascular surgery

o Periodic follow-up after cardiac transplant

205
Q

What are the possible complications of a coronary angiography?

A

o MI

o Stroke

o Renal failure

o Aortic or coronary dissection

o Cardiac rupture

o Air embolism

o Arrythmia

o Peripheral vascular damage

206
Q

What are the indications for a CABG?

A

o Asymptomatic or mild angina

o Stable angina

o Unstable angina

o NSTEMI

o Poor LV function

207
Q

What are the possible complications of a CABG?

A

o AF

o Stroke

o Acute renal failure

o GI bleeding

o Prolonged intubation a`nd its issues

o Death

208
Q

What are the indications for DC cardioversion?

A

o Narrow or wide QRS complex tachycardia (ventricular rate > 150) in an unstable patient

o AVNRT

o AF

o Atrial flutter

o Atrial tachycardia

o Monomorphic VT with pulses

209
Q

What are the possible complications of DC cardioversion?

A

o Thromboembolism

o Pulmonary Oedema

o Hypotension

o Myocardial dysfunction

o Skin burns

o St and/or wave changes on ECG

o Elevated levels of serum cardiac markers

210
Q

What are the indications for an implanted cardiac defibrillator (ICD)?

A

o LVEF < 35% due to prior MI

o LV dysfunction due to prior MI

o Survivors of cardiac arrest due to VF

o Haemodynamically unstable sustained VF

o Structural heart disease

o Syncope of undetermined origin with VT or VF

211
Q

What are the possible complications for an implanted cardiac defibrillator (ICD)?

A

o Infection

o Erosion

o Haematoma

o Pneumothorax

o Device Issues = lead dislodgement, inadequate defibrillation threshold, connection problems, lead malfunctions or fractures, electromagnetic interference

212
Q

What are the indications for permanent pacemakers?

A

o Second degree or third degree AV block with associated sympatomatic bradycardia

o Second degree or third degree associated with arrhythmias that would usually be treated with drugs that cause bradycardia, sinus pasues of > 3 seconds or asymptomatic escape rate < 40bpm while awake

o Type II second degree AV block with wide QRS

o Sinus node dysfunction with asymptomatic bradycardia

o Symptomatic chronotropic incompetence

213
Q

What are the possible complications for permanent pacemakers?

A

o Pocket complications = pocket haematoma, infection, erosion, wound pain, allergic reaction

o Pacemaker complications = lead dislodgement, pneumothorax, air embolism, cardiac perforation, extracardiac stimulation, VTE, coronary sinus dissection, Twiddler syndrome, device malfunction

214
Q

Define dyslipidaemia.

A

Elevated total or low-density lipoprotein (LDL) cholesterol levels, or low levels of high-density lipoprotein (HDL) cholesterol.

215
Q

What are the risk factors for dyslipidaemia?

A

o Poor diet

o Obesity

o Lack of exercise

o Smoking

o Age

o Diabetes

216
Q

What are the presenting symptoms of dyslipidaemia?

A

o Asymptomatic

o Chest pains or tightness

o Dizziness

o Heart palpitations

o Exhaustion

o Swelling of the ankles and feet

o Trouble breathing

o Cold sweats

o Nausea and heartburn

217
Q

What are the clinical signs of dyslipidaemia on examination?

A

o Corneal Arcus

o Xanthalasma

o Tendon xanthalasma

218
Q

What are the appropriate investigations for dyslipidaemia?

A

o Bloods = Serum lipid profile - total cholesterol, TG, HDL cholesterol, calculated LDL cholesterol, VLDL cholesterol

219
Q

What is the management plan for a patient with dyslipidaemia?

A
  • Statins
220
Q

Define Behçet’s disease.

A

A blood vessel inflammatory, multisystem disease that often presents with orogenital ulceration and uveitis.

221
Q

What are the risk factors for Behçet’s disease?

A

o Unknown cause

o Associated with HLA-B51

222
Q

What are the presenting signs and symptoms of Behçet’s disease?

A

o Recurrent oral and genital ulceration - very first symptom/sign

o Uveitis

o Skin lesions (e.g. erythema nodosum)

o Arthritis

o Thrombophlebitis

o Vasculitis

o Myo/pericarditis

o CNS symptoms

o Colitis

223
Q

What are the appropriate investigations for Behçet’s disease?

A

o Diagnosis is very clinical

o Pathergy Test = a needle prick becomes inflamed and a sterile pustule develops within 48 hours

o May measure complement levels and check for a positive family history

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